PSYCHASTHENIA: ITS CLINICAL ENTITY ILLUSTRATED BY

A CASE*

(Preliminary Paper.)

By Sidney I. Schwab, M.D.,

OF ST. LOUIS, MO.

In this paper an attempt will be made to give a more exact

definition to the term Psychasthenia, and to call attention to the
work of Pierre Janet in this connection and to illustrate some
of the ideas here set forth by a brief description of a case which
typifies, in a somewhat exaggerated form, perhaps, what is meant
in a clinical sense by the word Psychasthenia. Its justification
to a clinical entity in the classification of the so-called neuroses
is a matter which usage supported by the consensus of the best
neurological opinion alone, can decide.
It will not be out of place to mention at this point that Pro¬
fessor Janet’s visit to this country last year, at the time of the
Congress of Arts and Sciences at the Exposition at St. Louis gave
an opportunity to hear at first hand his views upon a subject in
neurology which he has made particularly his own. I count it
no little honor to be able to bring before you the effect of some
of his work, and to be able to illustrate by the recital of a case
which he himself, in conjunction with Dr. Putnam of Boston,
Dr. Fry and myself saw. This case Janet unhesitatingly pro¬
nounced to be psychasthenia instead of hysteria or neurasthenia,
or a combination of both.
At the clinical meeting of this society last year in St. Louis
I had the pleasure of presenting this case, and the contention was
then made by some of those present that there was little justifi¬
cation for considering it other than one or both of the above-
mentioned diseases.
It is apparent that multiplication of terms is entirely useless
unless by it some advance in knowledge is obtained, and yet no
evidence of the tendency toward such an advance is more striking
than the desire to limit more exactly the meanings which are im¬
plied in the terminology of diseases.

* Read at the meeting of the American Neurological Association, June

i, 2 and 3, 1903.
722 SIDNEY I. SCHWAB

A valuable contribution to this end has been made by Dana in

regard to neurasthenia, and a like attempt in respect to hysteria
would result in a like increase in our power to counteract its
effects.
The fact that we have at present no adequate conception of the
term hysteria makes the task all the more difficult, and the fact
that we are not likely to find one points unmistakably to the con¬
clusion that too many types of diseases and too many variations
of clinical pictures of diseases are without much thought classed
as hysteria. Perhaps if it were possible to exclude certain con¬
ditions which are not so definitely hysterical but are psychogenic
in their origin, it would be a step in the right direction of finally
determining just what we mean by hysteria; or if this is not pos¬
sible, of so limiting the term that it will lose much of the vague¬
ness with which tradition has involved it.
There are a certain number of cases met with now and then
for the explanation of which a diagnosis of hysteria leaves us dis¬
satisfied. In such cases there are to be found no anomalies of
sensation and none of the so-called stigmata of hysteria. No
objective symptoms commonly associated with hysteria are pres¬
ent, and yet in extreme cases such patients may become perma¬
nently incapacitated from taking part in the activities of their
former manner of living. In extreme examples of this condition,
in which is included the case which forms the subject of this
paper, a paraplegia develops in conjunction with a paralysis or
paresis of most of the voluntarily controlled muscles. Under¬
lying such a case will be found a mental state that is seldom found
in hysteria. The fundamental characteristic of this state of mind
from the point of view of differential diagnosis is its perfect pre¬
paredness for the symptoms as they appear, and a very accurate
perception of why they do occur.
Whatever conception of hysteria we may choose to incline to
and however broad we may make the meaning of the term neu¬
rasthenia, such a case leaves us without a satisfactory diagnosis,
unless we assume the existence of another category of functional
diseases. If this is granted, then the intimate psychology of the
development of the morbid state of mind which underlies the
condition may be capable of a somewhat clearer analysis.
In the introduction to his notable book “Obsessions et Psy-
 PSYCHASTHENIA 723

chasthenie” Janet sets forth his ideas in respect to psychasthenia

in part as follows:
“The diseases which form the object of this new study are
the obsessions, the manias, the folie du doute, tics agitations,
phobies, delires du contact, states of anxiousness, neurasthenias,
the bizarre sensations of strangeness and of depersonalization
often described under the term cerebrocardiac neuropathy, or
Krishaber’s disease. They have sometimes been classed under the
term degenerate deleriants, or neurasthenics, or phrenasthenics.
I have often designated them under the term doubters “les scrupu-
leux,” because doubt constitutes an essential characteristic of their
thought, and under the more precise term psychasthenic, which
appears to me to express feebly enough, it is true, the weakness
of their psychical functions. This collection of diverse symp¬
toms will permit the unification of many different diseases
into one, and it may be possible to construct a great psycho¬
neurosis modeled after that of epilepsy and hysteria. This will
tie psychasthenia, and will take the place of the obsessions, manias,
phobies, insanity of doubt, of contact and cerebrocardiac neu¬
roses.”
This might seem to be an ambitious attempt, and indeed from
a clinical point of view it is; but nevertheless, for Janet’s purpose,
which in this work at any rate is to submit these various states
to the most minute psychological analysis, it proves distinctly
feasible.
For the purpose of the present paper such a classification is
certainly too extensive, and the one case which is to be its illus¬
tration would be but a slender prop to support so large a clinical
differentiation. The much more modest purpose of submitting
this case and leading you to see that it justifies the term psy¬
chasthenia will be all that will be attempted.
If this much is admitted, then there is hope that the term
will be more exactly used with a more definite distinction from"
the diseases it might be confused with.
This case has been the subject of study and almost constant
observation for a period of six years. The patient is a physician,
and for that reason has himself been interested in the case as
a medical problem. Consequently it has been possible for me to
see more of the case than is usual with patients of this kind.
In brief, the outline of the case is as follows:
724 SIDNEY I. SCHWAB

Dr. G-, forty-three years old, comes of a very neurotic

stock. His mother has been a nervous invalid for many years,
with attacks of mental depression, alternating with excitement
and delusions more or less fixed. By the family physician this
condition has been called hysteria. A sister and brother have
been under my care for functional troubles of various kinds. In
fact, there is scarcely any member of the immediate family that
has not shown at one time or another some evidence of the neu¬
rotic strain mentioned above. The mother died a few months
ago, apparently as a result of an apoplectic stroke.
The patient had always been considered a somewhat delicate
child. In his school work he was always successful, and was
looked upon as an unusually gifted boy in point of intelligence.
As he grew to maturity there was very early to be observed two
opposing forces in his mental make-up, in respect to his rapidly-
growing ethical consciousness, a profound sense of duty and a
distinct disinclination, amounting in some instances to physical
repugnance to carrying out the conclusions which this sense made
so obvious to him. Added to this was a strong religious incli¬
nation which seemed even this early to form a background to
much of his deeper thought.
Of previous sickness other than the one antedating the be¬
ginning of his present trouble there need nothing be said except
that there was always a lack of physical, though never of mental,
vigor.
Coming to this country at the age of 25, he found that the
knowledge of law gained in his university was of little service to
him in the legal profession. He determined then to study medi¬
cine, as it appeared to him that in medicine the surest and most
rapid advance might be made. It is to be observed that he had
a natural repugnance to the study of medicine, but his sense of
duty compelled him to this decision. He was a good student,
graduating high in his class. He obtained the usual hospital
position, and after his service was completed he decided to spend
a year as assistant in the St. Louis Insane Asylum.
Again in this instance he followed the dictates of what he con¬
ceived to be his duty against his most evident disinclination, for
he had a morbid fear of the insane and a most intense distaste for
mental diseases His work there was very satisfactory to all con-
 PSYCHASTHENIA 725

cerned but himself, and he left very nearly exhausted by the

struggle.
In practice he obtained a fair measure of success, fighting al¬
ways against the mental state mentioned before. He represented
in his practical work a man doing work well for which he had
neither taste nor the consciousness that it was the work he could
do best. After several years of general practice he decided to
specialize in nose and throat. His reason for doing this was a
hope that in the limitation of his activity he might obtain the
peace of mind which had so long been denied him. He was
active and successful in his new field until an attack of influenza
in December, 1895, caused his final breakdown. Against this
he struggled at the advice of his physician and attempted various
sorts of exercise in the hope of overcoming a paralysis of his
will, which his physician explained to him was the cause of his
gradually increasing difficulty in moving about. This explana¬
tion plays an important part in the subsequent history of the
case forming the nucleus of an idea which became more and more
fixed as time went on.
Very gradually, but progressively, Dr. G-lost the power
of voluntary control of the muscles of the four extremities until
he became a bedridden invalid or a prisoner in an invalid chair,
unable to help himself, at times unable to move a single volun¬
tarily-controlled muscle in his body. After a year spent in a
hospital in St. Louis and another year at a sanitarium in Michi¬
gan he returned to St. Louis to the Baptist Sanitarium, where he
has been ever since, practically in the same condition. In the
summer of 1899 I saw him f°r the first time.
A physical examination made at that time and repeated many
subsequent times showed an absolutely intact nervous system, ex¬
cept the total paraplegia of all four extremities. All reflexes
were normal. There was perfect control of the sphincters.
There was an intense atrophy of all the muscles, but so evenly
distributed that disuse could satisfactorily explain it. The elec¬
trical examination showed normal conditions. There was no
objective sensory symptom of an abnormal kind to be found.
There was marked emaciation, but no more than would be nat¬
ural in a case of this kind. The urine, blood, heart, lungs, etc.,
were normal. From the subjective side there was a collection
of the most bizarre and curious paresthesia. It is sufficient to
726 SIDNEY I. SCHWAB

say that recently a physical examination showed practically the

same results except that there had developed a marked emphy¬
sema of both lungs, totally obscuring the heart’s area. It is
probable that this is due to the superficial breathing which the
patient has had for so many years.
During the time of my observation of the case the patient
has presented a great variety of curious symptoms, the analysis
of which will be left to another time. In general, it might be
said that the following groups of symptoms lasting for
weeks or months might be of interest from the point of view of
this paper. For periods of a few weeks to a few months the
patient has presented the interesting phenomenon of a presum¬
ably involuntary paralysis of all the extrinsic muscles of the eye¬
ball. This was at times accompanied by a sort of spasmodic
contraction of the muscles of the jaw which prevented him from
opening his mouth except for a very small space, only sufficient to
admit liquid food. There developed at times a double-sided pto¬
sis, which disappeared without leaving any trace. There was
also a temporary paralysis of the mechanism of deglutition,
which necessitated rectal feeding for a time. About two years
ago developed a peculiar series of automatic movements, espe¬
cially marked in the arms, though present to some extent in the
lower extremities. These movements were to a certain degree
under the control of the will, but their full performance was
subject to such variations of control that as a rule the move¬
ments were overacted; that is, they were not finely coordinated,
so that there was a peculiar jerkiness to them that resembled
to a certain extent tabetic movements. These are only a few of
the more important curious phenomena which this case has pre¬
sented from time to time.
It should be noted that during all this time there was no
appreciable mental change. The patient to-day retains full vigor
of intellect and employs himself in reading history, travels, phi¬
losophy and other books of a like nature; in fact, it is interesting
to note that mentally he appears to have deepened his powers of
thought, especially in directions of analysis. His disinclination
to talk, much increased of late, has prevented an insight into the
deeper psychology of many of these phenomena which his growth
in analytic power might have made deeply interesting.
This, in brief, is an outline of the case, and any explanation
 PSYCHASTHENIA 727

which might be made must be based upon as clear a conception

as is possible to obtain of the state of mind which the patient has
presented to himself. The evidence of Dr. G-himself forms
a body of observations which must be acknowledged are worthy
of respect and should be the groundwork of any hypothesis
which we advance. The main fact to be obtained in this way is the
statement that in no part of his life has he felt that his power has
ever been equal to the necessary performance which has been
imposed upon him. From boyhood to the present time this un¬
certainty has been one of the accepted facts of his life probably
the most apparent. So long as this had to do purely with the
activities of a physical nature, he was enabled to get through
them in some way or another. At the point when the purely
muscular functions became involved as a result possibly of the
influenza attack there developed the paralysis and the purely mo¬
tor phenomena. If we grant that this is a reasonable explana¬
tion of the origin of the paralysis, then we can easily see why
it is that this state has persisted and will likely persist as long
as the patient lives. There is no doubt in the patient’s mind, and
there never has been, of his ability to move his muscles to
walk, if necessary; to rise from his chair if the occasion required.
The point is that any such effort would appear to him a useless
exercise and a futile using up of what volitional power there
remained left to him. He has made for himself a material con¬
ception of the amount of voluntary power which he as an individ¬
ual possesses, and this amount he prefers to leave undiminished.
There exists for him no obvious reason why he should change
his present condition for one which would awaken in him the
old struggle against doubt and uncertainty. This is the point, to
my mind, which differentiates this case immediately from hys¬
teria. The attitude of this patient’s mind is and always has
been perfectly conscious. As far as I have been able to as¬
certain, there has never been a symptom which the patient did not
perfectly understand, as far as his understanding went. Hyster¬
ical phenomena are most easily appreciated if we assume that
their origin at least is purely sub-conscious. We are all ready
to acknowledge, I believe, that an hysterical patient is unaware
of the anomalies which he presents until his attention is directed
to them by examination or observation. In this case, however,
the symptoms have been a result, we might say, of an almost
728 SIDNEY I. SCHWAB

conscious adaptation to the patient’s assumed inability for any

sort of an active life. In this statement the obsession of the
fixed idea comes to the front, and the basis of the contention
that this is a case of psychasthenia might be said to rest here.
A patient with his psychical self so deeply pinned down to a
sense of his own powerlessness, thus giving way to the morbid
introspectiveness markedly present from the start, might very
readily develop any symptom or group of symptoms which this
patient has presented.
For Janet, doubt, indecision, a consciousness of incapac¬
ity, are typical traits of the psychasthenic’s mental make-up. In
this sense, at any rate, this patient is a psychasthenic. In think¬
ing over this case I have often thought that the term psychical
paralysis might adequately describe the condition. The objec¬
tion to this is that paralysis always assumes a motor function,
and here we have a state of lowered activity of the mind itself.
The term paralysis is open to the same objection, and in addi¬
tion this term is already in use for an entirely different symp¬
tom-complex. So, after all, the designation psychasthenia
leaves us more satisfied than any other. If this exaggerated
case can be so described and can be justly set down as belong¬
ing to a neurosis that is neither hysteria nor neurasthenia, then
there is a wide field for the investigation of milder cases for
which there has, up to this time, been no satisfying explanation.
In conclusion it might be a point of interest to note that the
patient himself has often stated that he looked upon himself as
a sort of Hamlet, and the more one thinks of this the more one
sees the justice of the comparison.